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May 25, 2009

Decisions, Decisions, Decisions
By Annie Macios
For The Record
Vol. 21 No. 11 P. 20

If implemented properly, clinical decision support systems can be powerful tools in the quest for cost-efficient, quality healthcare.

Those who have received unsolicited advice often have a take-it-or-leave-it approach to the information. But what about automated advice that could make a difference in a patient’s treatment? Clinical decision support systems (CDSS) deliver automated decision support information to physicians at the point of care and have achieved a high rate of acceptance. When implemented properly, experts agree that the technology improves workflow and, ultimately, patient care.

Jonathan Teich, MD, PhD, chief medical informatics officer at Elsevier who has more than 20 years of experience working with CDSS, believes the technology is a useful tool that can make a positive difference in patient care. A good CDSS, according to Teich, can do several things: sense and filter information about a situation and provide information to optimize the solution. “But what physicians need to know at a given moment—the facts and actions that are most relevant at this point in the workflow—those are the most important pieces of information to have available immediately at the point of care and decision making,” he says.

“As a practicing physician, the CDSS saves huge amounts of time for me,” Teich adds. “If I have quick information on how to handle a situation, it helps. I get filtered information, which saves time, as well as alerts and reminders, which also save time in keeping me updated with the huge volume of information available.”

Teich says there are four parts to a well-built CDSS. First, the system must be able to sense what is going on and filter the information. Next, it must be able to inform the practitioner of the issues related to his or her patient. It must give enough information to let the practitioner make a decision with confidence and, finally, make it easy for the physician to take whatever action he or she chooses. Teich says that while the acceptance rate for CDSS interventions typically is not 100%, a rate in the 40% to 80% range is acceptable.

CDSS tools can also scan databases and give facilities or physicians a dashboard of their performance to let them know how their practice is doing in relation to the system’s guidelines. “It can filter performance in different areas and then focus alerts in areas that need improvement. In this way, the CDSS not only tries to provide just the information needed but also helps measure progress,” Teich notes.

Staying Up-to-Date
Keeping the guidelines and standards current and updated is an important aspect of CDSS. “There currently isn’t a standard way of letting one institution’s information filter to another,” Teich says. “With new guidelines, there is a lot of work in translating that guideline, and once it’s finished, this doesn’t necessarily mean that it will be useful to another institution.”

Some customization is available, but there are already many rules and guidelines that are common and consistent across the country for preventive care, particularly in the areas of mammography, colonoscopy screening, and pneumonia.

There isn’t a consistent way of updating CDSS across the board yet, but many tools are automatically updated by the supplier or vendor. Items such as drug lists are kept current by drug manufacturers, and more of the responsibility for such tasks is falling to product developers. At present, updated information simply appears in the system, but Teich predicts that going forward, practitioners will subscribe to the topics of most interest to their field, especially for decision support in new areas, where they’ll want as much information as possible.

Putting It in Practice
Hal Scott, vice president of IT systems and chief information officer at MCGHealth in Augusta, Ga., has employed a CDSS for several years. “We saw efficiency in clinical information systems and developed a strategy to implement them at our facilities,” he says.

During the system selection process, Scott says MCGHealth had two choices: going best of breed, which would have required interfacing differing systems, or employing an integrated system.

After the decision was made to go with the latter option, “We began the first application in 2004, and we’re now using it for pharmacy, laboratory, radiology, nursing, CPOE [computerized physician order entry] and are going live with electronic medical administration record,” Scott says. “We’ve made substantial progress over time. We are fortunate that our organization made the bold move forward in the early 2000s toward the EMR [electronic medical record].”

At MCGHealth, the clinical information systems have been implemented with regard to many aspects of the EMR, especially those centering around CPOE. “For example, it looks to make sure certain key data elements are present when physicians enter an order, then prompts them to do the things that they should. It’s nice to have that reminder to help them complete the process according to protocols,” says Scott.

To make CPOE more effective, the organization has created various institutional order sets. Based on a particular situation (eg, at admission), the system will notify the practitioner regarding what needs to be ordered for that particular patient. If the physician agrees with the recommendations, he or she moves forward based on institutional protocols.

Scott notes, however, that it takes time to get the order sets fine-tuned. “Every patient treated is an individual; the physician has the choice to choose the order set, add to it, or subtract from it. The clinical decision support is based on clinical guidelines and protocols,” he explains.

At MCGHealth, there is a defined process to establish the guidelines that appear in the CDSS. First, current physician practices are analyzed to determine how they are currently being performed. Then, the physicians agree to a set of new orders, which need to be reviewed by the pharmacy and therapeutics committee. Next, a medical management team examines how the directives will affect the workflow of the ancillary services involved in patient care. A physician executive team gives a final confirmation before the IT department implements the standards into the system.

“We update standards on a regular basis so that physicians and caregivers know when to expect them,” Scott says. “We regularly notify them when changes are made to the order sets and update the same time every week. The key to success is having very good communication regarding the updates, so everyone knows when [they] occur.”

By using the order sets, there has been improved workflow on the inpatient side. Scott also mentions the importance of understanding the workflow to ensure that the system is easy and quick to use. For example, in the intensive care unit environment, extra attention must be given to developing the order sets because the pace of activity is faster.

Because knowing what is in the environment is so important, Scott recommends laying out a change control process. “For example, when a medication recall is issued by the FDA, we must know that we can track every mention of that medication in the system,” he explains. “It must be deliberate, and with IT’s change control process, we can be certain that the updates are done properly.” He notes, however, that the CDSS should not be considered an IT system. At MCGHealth, the physicians are considered the system owners, with IT lending support to the clinical environment.

The CDSS can also identify drug-drug interactions, perform dosage calculations, spot drug allergies, and provide descriptions of the drug listing side effects. The system’s protocols permit documenting nurses to view drug-drug and drug-allergy interactions, as well as additional information or evidence they can use to learn more about a patient’s care plan.

Optimistic Outlook
Charlie Whelan, director of consulting in the Healthcare & Life Sciences Group at Frost & Sullivan, believes decision support systems are an important component of where HIT needs to go.

While CDSS will achieve their full potential as part of the EMR, most of today’s systems are not yet linked, says Whelan, who adds that most hospitals’ EMRs are not sophisticated enough to handle that assignment.

Whelan views the current market for CDSS tools primarily as those delivered via handheld technology, such as Palm Pilots and iPhones. “The doctor has a PDA, the information is updated, and he can use a checklist of questions and other content to support patient care,” he says.

Whelan says CDSS technology is more popular among younger physicians because they are more tech savvy and don’t trust their judgment as much as their more experienced counterparts. “There is a huge market with medical students; often medical schools will issue PDAs to their students to use as a learning tool,” he says.

The information, while not patient specific, is presented in an encyclopedia-like format that offers a checklist to help with a diagnosis. The ability to connect the decision tools to the EMR gives the technology additional juice. “Where the value kicks in is when the patient information is tied to the clinical support,” says Whelan, adding that hospitals should develop facility-specific standards in addition to the universally accepted standards such as drug-drug interactions.

Whelan says there is a trend toward more hospitals creating guidelines that are germane to their facility. Also, healthcare societies have begun developing standards in conjunction with companies that develop CDSS technology. Putting all these pieces together and delivering them in a “digestible” format that is physician friendly will be the key to this technology’s success, he adds.

Barriers to Implementation
In today’s healthcare environment, where doctors are forced to do more in less time, CDSS technology can be viewed as more of an obstacle than a tool that will increase efficiencies. Simply put, many physicians do not want to add another step in the patient care process. However, “Order sets reduce time and allow for decision making based on the best clinical evidence they have today from inside and outside the facility,” Whelan says. “It makes it significantly faster than doing everything by hand.”

It’s important not to overwhelm physicians with alerts and updates, which can lead them to not use the system. “CDSS is a balancing act. You have to select alerts and reminders very carefully or it will encumber physicians with ‘alert fatigue’ and the alerts become less meaningful,” Scott says. “You need to constantly review alerts based on practice patterns and delete alerts when they are no longer useful.”

Teich says the following three conditions need to occur if CDSS adoption rates are to improve:

• Vendors must ensure that systems are as usable and workflow friendly as possible.

• More standards and avenues of information sharing must be in place to eliminate the need for myriad facilities to reinvent standards.

• The CDSS must fit into what Teich calls the “business of medicine.”

“With new financial incentives for the delivery of proper care and following quality guidelines, facilities must realize that better care means better business. CDSS are a critical component in facilitating better care. A well-implemented system plays a big factor in increasing safety and improving patient care,” says Teich, who adds that from an IT standpoint, the focus is on making the technology convenient, speedy, and easy to use. From a medical perspective, it must provide reliable information that presents physicians with the best treatment options.

Whelan points out the importance of the system having the flexibility to allow physicians to override the CDSS based on patient interaction and personal opinion. “There is still the important facet of the physician gaining invaluable information by talking with the patient. Physicians need to be sure they are in control of the decisions being made. They want the flexibility to make the best decisions based on the best information,” he says.
Teich says CDSS have a track record of success, while Whelan is anxious to see how the “conflict” between man and machine plays out.

“Systems that have been implemented correctly in design and communication have achieved great success. They deliver information to clinicians when it is needed to ensure that the best choices are made regarding patient care,” says Teich.

“There is a lot of acceptance of this technology by many types of physicians. I think we’ll continue to see significant growth in this area,” Whelan says. “One thing that is important to remember is that medicine remains an art and is ‘human.’ This technology will continue to challenge us to think about what medical decisions will be in control by clinicians vs. computers.”

Scott also recognizes the need for facilities to keep pace with the technology to optimize its value. “Keeping the CDSS current and useful is a never-ending process, and we’re always trying to improve it,” he says.

— Annie Macios is a freelance writer based in Doylestown, Pa.